An Overview of Percutaneous Endoscopic Gastrostomy Tube Placement in the Intensive Care Unit

Home , Feeding tube, Gastropexy, Nasogastric intubation

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Review Article on Interventional Pulmonology in the Intensive Care Unit

An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit

Margaret Wei1, Elliot Ho2, Pravachan Hegde2

1Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA, USA; 2Division of Advanced Interventional Thoracic Endoscopy/Interventional Pulmonology, University of California San Francisco – Fresno, Fresno, CA, USA Contributions: (I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: None; (V) Data analysis and interpretation: None; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Pravachan Hegde, MD. Division of Interventional Pulmonology, 155 North Fresno Street, Fresno, CA 93701, USA. Email: [email protected].

Abstract: Critically ill patients are at increased risk for malnutrition as they often have underlying acute and chronic illness, stress related catabolism, decreased appetite, trauma and ongoing inflammation. Malnutrition is recognized as a leading cause of adverse outcomes, higher mortality, and increased hospital costs. Percutaneous endoscopic gastrostomy (PEG) tubes provide a safe and effective route to provide supplemental enteral nutrition to these patients. PEG placement has essentially replaced surgical gastrostomy as the modality of choice for longer term feeding in patients. This is a highly prevalent procedure with 160,000 to 200,000 PEG procedures performed each year in the United States. The purpose of this review is to provide an overview of current knowledge and practice standards with regards to placement of PEG tube in the Intensive Care Unit (ICU). When a patient is considered for a PEG tube, it is important to evaluate the treatment alternatives and identify the best option for each patient. In this review, we provide the advantages and disadvantages of various feeding modalities and devices. We review the indications and contraindications for PEG tube placement as well as the risks of this procedure. We then describe in detail the per-oral pull, per-oral push, and direct percutaneous techniques for PEG tube placement. Additionally, we review the feasibility of having interventional pulmonologists place PEG tubes in the ICU.

Keywords: Percutaneous endoscopic gastrostomy (PEG) placement; interventional pulmonology; Intensive Care Unit (ICU)

Submitted Jan 18, 2020. Accepted for publication May 06, 2020. doi: 10.21037/jtd-19-3728 View this article at: http://dx.doi.org/10.21037/jtd-19-3728

Introduction technique first described by Gauderer et al. in 1980 (3). PEG placement has essentially replaced surgical Critically ill patients are at increased risk for malnutrition, gastrostomy as the procedure of choice for a longer term particularly given their underlying acute and chronic illness, feeding in patients. PEG tubes allow for enteral feeding stress related catabolism, decreased appetite, trauma and when oral feeding is not possible or insufficient. This is a ongoing inflammation (1). Malnutrition is recognized as a highly prevalent procedure with 160,000 to 200,000 PEG leading cause of adverse outcomes, higher mortality, and procedures occurring each year in the United States. increased hospital costs (2). The purpose of this review is to provide an overview Percutaneous endoscopic gastrostomy (PEG) tubes of current knowledge and practice standards with regards provide a safe and effective method to provide supplemental to placement of PEG tubes in the Intensive Care Unit enteral nutrition to these patients. PEG placement was a (ICU). Additionally, we consider the feasibility of having

© Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2021;13(8):5277-5296 | http://dx.doi.org/10.21037/jtd-19-3728 5278 Wei et al. PEG tube placement in the ICU interventional pulmonologists place PEG tubes in the ICU. placement of the NGT with this device and showed that localization with this device correlated with that of plain film radiography (13). Feeding modalities Li et al. studied the feasibility of deploying a flexible When a patient is considered for a PEG tube, it is important uteroscope inside a gastric tube to provide visual guidance to evaluate the treatment alternatives and identify the best for placement of the gastric tube. With this method, there option for each individual patient. Below we consider the was an increase in rate of successful tube placement and advantages and disadvantages of various feeding modalities reduced time for tube placement. This study also noted an and devices. overall operator preference for the visual system over the conventional method (14). Sun et al. has studied the use of electromagnetic tracking system to identify the location of Parenteral vs. enteral the NGT during the insertion process. With this technique, Parenteral as compared to enteral nutrition has been a permanent magnet is embedded within the tip of the NGT associated with higher costs of care, increased risk of both and a wearable device with embedded sensors is placed at the bacterial and fungal infections, particularly central line neck, which senses the passive magnetic field of the NGT as associated infections, hyperglycemia, as well as longer it traverses the esophagus into the stomach (15). ICU length of stays. However, there is no difference in the These navigational systems have yet to be adopted into mortality (4-9). standard clinical practice. However, in the future we may A recent multicenter randomized control trial found no see increased adoption of these systems given the risk difference between patients receiving parenteral and enteral of aspiration, pneumonia, pneumothorax, hemothorax, feeding with regards to 30-day mortality, but did find an esophageal perforation, or in some cases even death with increased risk of hypoglycemia and vomiting with enteral incorrect placement of NGTs (16,17). feeding (10). Nasoenteric tube placement is a known risk factor for Also, one recent review found no difference between nosocomial sinusitis. These tubes can cause obstruction of parenteral and enteral feeding in mortality, ventilator free the nasal ostia and provide a conduit for colonization of the days, aspiration, or pneumonia. It did however find that nasopharynx by gastric microorganisms. One prospective enteral nutrition may be associated with lower risk of sepsis epidemiologic study performed in ICU patients noted that as compared to parenteral nutrition (RR 0.59, 95% CI, feeding through a NGT was associated with increased 0.37–0.95) (11). risk of sinusitis (OR 14.1, P=0.015) (18). A subsequent epidemiologic study also found that while there was an overall low incidence (0.15%) of nosocomial sinusitis, the PEG vs. nasogastric/nasoduodenal/nasojejunal feeding combination of nasoenteric and endotracheal intubation Temporary enteral access can be achieved with nasogastric was associated with increased odds of sinusitis compared (NG), oral gastric (OG), nasojejunal (NJ), or oral jejunal with endotracheal intubation alone (19). (OJ) feeding tube. These options are recommended for Furthermore, prolonged use of NGTs can lead to short-term use, when feeding is required for a few days or nasal and esophageal ulcerations, aspiration pneumonia, up to one month. and gastroesophageal reflux disease. These tubes can also Bedside enteric tube placements are commonly used in cause trauma to the stomach, peptic esophagitis, stricture the hospital and long term care environments. NG, OG, NJ, formation, and even tracheoesophageal fistula formation (20). OJ can be placed blindly with confirmation of appropriate These complications are less of a concern with PEG positioning by auscultation and radiography (12). tubes, which enter the stomach directly, bypassing the A variety of novel systems for navigational guidance nasopharynx and esophagus. PEG tubes also have lower during nasogastric tube (NGT) placement are currently rates of intervention failure and offer patients an improved being studied. Rivera et al. evaluated the use an quality of life. As such they are preferred for longer term electromagnetic tube placement device whereby the tip of nutrition. a nasogastric feeding tube emitted electromagnetic pulses, One systemic review evaluated rates of intervention which were picked up by sensors on a receiver placed on the failure (e.g., feeding interruption, blockage or leakage of the epigastric region. He demonstrated successful post-pyloric tube, treatment non-adherence) and concluded failure rates

© Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2021;13(8):5277-5296 | http://dx.doi.org/10.21037/jtd-19-3728 Journal of Thoracic Disease, Vol 13, No 8 August 2021 5279 in the PEG tube population were significantly lower than also showed improvement in mortality (29). failure rates in the NGT population at 9.22% and 39.11%, Current European Society for Clinical Nutrition and respectively (RR 0.18, 95% CI, 0.05–0.59, P=0.005). Metabolism (ESPEN) and American Society of Parenteral However, the review failed to demonstrate differences in and Enteral Nutrition (ASPEN) guidelines recommend mortality, complications of the intervention, aspiration consideration of starting enteral nutrition after 24–48 hours rates, and nutritional status (21). in the ICU. Enteral nutrition is recommended over parenteral nutrition when clinically appropriate (30,31). However, the majority of mechanically ventilated patients Gastric vs. post-pyloric enteral feeding who receive enteral nutrition do not receive sufficient While PEG is often the preferred method of providing caloric intake to meet their daily energy requirements (32). long term enteral nutrition, the concern with gastric While the use of enteral nutrition alone often does feeding is the risk of aspiration, particularly in critically not meet the caloric needs, early initiation of parenteral ill patients who may have delayed gastric emptying and nutrition to supplement enteral nutrition has not been altered mentation. Post-pyloric feeding may be preferred proven to be beneficial. One randomized control trial in patients with gastroparesis, gastric outlet obstruction, demonstrated that delayed parenteral nutrition in these or history of gastrectomy. There are different methods to patients was associated with shorter ICU length of stay, achieve post-pyloric feeding. The percutaneous endoscopic shorter duration of mechanical ventilation, shorter hospital gastrojejunostomy (PEG-J) is commonly used and is length of stay, and reduced hospital costs (33). achieved by advancing a smaller tube through a PEG tube While early feeding is recommended in the critical with placement of the distal end of the smaller tube in the care setting, there has been conflicting evidence regarding jejunum. An alternative approach is achieved through direct whether high calorie feeding or trophic feeding offers percutaneous endoscopic jejunostomy (PEJ), whereby a greater benefit. A recent study has illustrated the feasibility large bore feeding tube is directly placed in the jejunum of early trophic feeding in patients with septic shock as a under endoscopic guidance (22). PEG-J and PEJ tubes potential approach to improve enteric immune function are more technically challenging to place and require during the hyper-acute phase of sepsis (34). specialized equipment and training, but may offer an However, one randomized control trial evaluated patients advantage over PEG by minimizing aspiration risk. with acute lung injury and found that initial trophic feeding One meta-analysis found that PEJ was able to reduce for 6 days as compared with early full caloric feeding did not gastric residual volumes and was more likely to meet the improve ventilator free days, 60-day mortality, or incidence energy requirements of a patient, but did not provide of pneumonia, but did lower the risk of gastrointestinal significant benefit over PEG tubes (23). Another study complications (35). A subsequent study also demonstrated in trauma patients also found that patients who utilized that permissive underfeeding was associated with no PEG-J for post-pyloric feeding and gastric decompression difference in feeding intolerance (e.g., vomiting, abdominal were able to reach their goal rates faster than patients with distention, or gastric residual over 200 cc), diarrhea, ICU- PEG. However, there was no difference in ventilator days, associated infections, or mortality when compared to full pneumonia, sepsis, or hospital length of stay (24). caloric feeding (36). Several recent meta-analyses found evidence demonstrating lower rates of pneumonia with post-pyloric Patient selection feeding compared with gastric feeding. Nonetheless, there was no difference in ventilator days or mortality between PEG is indicated for patients who require long-term the two groups in these studies (25-27). nutritional support (>30 days) and have a functional gastrointestinal tract, but without sufficient oral intake (37). Neurologic dysphagia is one of the most common Timing of feeds reasons for PEG tube insertion. Neurologic indications Some studies have suggested that early enteral nutrition include stroke, dementia, amyotrophic lateral sclerosis reduces the risk of mortality in critically ill patients as (ALS), Guillain-Barré Syndrome, Parkinson’s disease, compared with delayed initiation of enteral nutrition (28). cerebral palsy, multiple sclerosis (MS), myasthenia gravis, Early enteral nutrition for stroke patients with dysphagia Huntington’s disease, encephalitis, meningitis, and

© Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2021;13(8):5277-5296 | http://dx.doi.org/10.21037/jtd-19-3728 5280 Wei et al. PEG tube placement in the ICU polymyositis (38). Society (AGS) guideline recommend oral feeding over PEG PEG tube insertion is also common in patients with tube placement in patients with dementia (46). physical obstruction of the upper gastrointestinal tract as Nevertheless, about one third of nursing home patients seen with head and neck cancers, esophageal cancers, or with dementia have PEG tubes (47). Hospital characteristics trauma. PEG tube placement can also be indicated for associated with higher rates of feeding tube placement decompression, such as in gastric outlet obstruction. include larger sized hospitals, for-profit hospitals, and hospitals with more ICU days documented for chronically ill patients within the last 6 months of life. Cerebrovascular disease/stroke Black and Hispanic patients with dementia also have Dysphagia can occur in up to 65% of patients with stroke. higher rates of PEG tube placement (48). It is unknown at George et al. found that 8.5% of patients hospitalized for this time if this is a result of cultural differences, disparities stroke received tracheostomy in addition to PEG tube in health care access, or discrepancies in physician placement. Receiving a tracheostomy during an admission communication. Physician misperceptions regarding the was the strongest predictor for subsequently receiving a utility of PEG tubes are also often a contributing factor to PEG on that same admission (adjusted odds ratio 0.27, the overuse of PEG tubes in patients with dementia despite 95% CI, 0.24–0.29). Early PEG tube placement (<7 days) evidence to the contrary (49,50). during a hospitalization for stroke was associated with shorter length of stay, greater odds of discharge to home or Head and neck malignancy acute rehabilitation, and lower odds of discharge to skilled nursing or long-term care (39). Head and neck cancer is a common indication for PEG Patients with higher stroke severity, worse dysphagia tube placement. Patients with head and neck cancers can severity, diabetes, history of prior intracerebral hemorrhage, experience difficulty swallowing for a variety of reasons increased age, and health insurance coverage have a including pain, obstruction by the tumor, or chemo- significantly increased likelihood of PEG placement (40). radiation side effects including mucositis. In fact, dysphagia occurs in up to 54% of patients with advanced head and neck cancer treated with chemo-radiation (51). Motor neuron disease/ALS One review showed that of all head and neck cancer ALS is a rapidly progressive neurologic disease that leads patients studied, 30.5% had a gastrostomy tube placed at to quadriplegia, dysarthria, and dysphagia. PEG placement some time. Of all patients who receive treatment, 35.1% in ALS has been shown to be safe even in patients with had a gastrostomy tube placed. Of those who had tubes pulmonary dysfunction and may improve quality of life placed, 16.9% had their gastrostomy tubes placed before (41-43). treatment and 83.1% were placed after treatment (52). Given that many patients with head and neck cancer often have a long term need for enteral nutrition, some Dementia studies have evaluated the use of prophylactic PEG tube In the advanced stages of dementia, patients often placement for patient with head and neck cancers and develop feeding issues that can arise from difficulty with have found this practice to be safe and effective without physically feeding themselves, controlling a food bolus, and increasing the risk of long term dysphagia (53). swallowing. They may have difficulty recognizing food and Prophylactic PEG tube placement in patients with have malfunction with the limbic and hypothalamic systems advanced head and neck cancer may also minimize weight that regulate hunger and satiety. PEG tube placement in loss during chemo-radiotherapy as compared with reactive patients with dementia is very common and the decision to PEG tube placement. Delayed PEG placement may be place a PEG tube is often influenced by family member or associated with increased risk of aspiration and stricture. caregiver concerns that the patient may starve. However, in However, timing of PEG tube placement does not improve patients with dementia, enteral feeding via PEG tube has tumor control or overall survival (54-56). not been shown to improve the risk of aspiration, pressure Alternatively, NGT remains a viable option to PEG tube ulcers, pneumonia, or mortality as compared with oral placement in these patients. One recent study in patients feeding (44,45). As such, the current American Geriatric with head and neck cancer found that while PEG provided

institution, we use the Boston Scientific EndoVive™ 20 French Safety PEG kit (Figure 1) using the per-oral pull technique described below (Table 1). The endoscope is passed into the stomach, which is then insufflated to achieve maximal apposition of the gastric and abdominal walls. A full esophagogastroduodenoscopy (EGD) is done to ensure that there is no obstruction or malignancy prior to PEG tube placement (Figure 2). This is critical to rule out any post-pyloric obstruction. Any abnormality should be documented. The gastrostomy site is located with a combination of trans-illumination and finger Figure 1 Boston Scientific EndoVive™ 20 French Safety PEG kit, indentation of the abdominal wall (Figure 3A,3B). The ideal Pull technique. PEG tube location should be at the gastric antrum. Local anesthetic (lidocaine 1% with epinephrine) is infiltrated subcutaneously, and while maintaining a 90-degree angle better weight management, patients with NGT placement with the abdominal wall, the local anesthetic is injected into had the device in place for a significantly shorter period the tract (Figure 3C). of time. The PEG tube was often considered by patients A small skin incision is made to allow insertion of a to be more cosmetically appealing and more convenient. needle-catheter combination also called trocar catheter There were no quality of life differences between the two (Figure 3D-3F). The trocar catheter is then inserted along study groups. NGT was associated with increased risk of the designated tract into the stomach. There is a risk of dislodgement, but even accounting for this difference, PEG colonic interposition between the gastric and abdominal tubes were costlier (57,58). walls during this procedure. As such, in addition to trans- illumination and finger indentation, direct visualization with aspiration of the needle syringe provides additional Gastric decompression reassurance that there is no colonic interposition. If the PEG tube placement for gastric decompression has also needle is not directly visualized entering the stomach wall, been described as a feasible palliative option for patients but reflux of air is noted in the syringe, this may indicate with malignant bowel obstruction, but is often associated inadvertent puncture of the transverse colon. with higher risk of complications and poor prognosis Once within the stomach, the needle is removed and (38,59,60). the small wire loop at the end of the guidewire is passed through the catheter (Figure 3G). During this phase of the procedure, it is critical not to damage the posterior wall Miscellaneous of the stomach during needle insertion. A snare system is PEG tube placement has been described in patients with passed through the endoscope and secures the wire loop Crohn’s disease, cystic fibrosis, severe trauma, and altered (Figure 3H). The wire loop is then pulled up through the level of consciousness (61). esophagus and out of the mouth (Figure 4A). In the Ponsky technique (per-oral pull), the wire exiting the mouth is attached to the feeding tube. The wire and the Procedure feeding tube are then pulled down through the esophagus, There are three main techniques for PEG tube placement: into the stomach, and out through the anterior abdominal the per-oral push technique, the per-oral pull technique, wall. It is important to lubricate the tube for smooth and the direct percutaneous technique. placement (Figure 4B). A skin disc (external bolster) is then placed over the feeding tube (Figure 5A). While visualizing the internal bumper with the endoscope, the external Per-oral pull technique bolster is adjusted until the internal bumper is flush against The most commonly used technique is the pull method as the anterior stomach wall. originally described by Gauderer et al. in 1980 (3). At our The external bolster is kept between 2–5 cm as indicated

Table 1 The Per-oral pull technique for percutaneous endoscopic gastrostomy tube placement Steps Description Reference Image

1 Gather all necessary equipment Figure 1

2 Perform an esophagogastroduodenoscopy Figure 2

3 Confirm gastrostomy location externally with trans-illumination and internally with finger indentation Figure 3A,3B

4 Infiltrate the region with local anesthetic including the intended tract of the gastrostomy tube Figure 3C

5 Make a small skin incision with a scalpel Figure 3D

6 Insert the needle-catheter combination (trocar) through the incision and into the stromach Figure 3E

7 Visualize passage of the needle-catheter combination through the anterior gastric wall with the endoscope Figure 3F

8 Remove the needle, leaving the catheter in place Pass the wire loop through the catheter into the stomach Figure 3G

9 Using the endoscope, snare the wire loop Figure 3H

10 With the endoscope, pull the loop up through the esophagus and out of the mouth Figure 4A

11 Apply lubricant to the gastrostomy tube Figure 4B

12 Thread the wire loop through the tip of the gastrostomy tube Figure 4C

13 Loop the head of the gastrostomy tube through the wire loop, securing the two pieces together with a knot Figure 4D

14 Apply firm pressure while pulling the wire and gastrostomy tube through the anterior abdominal wall Figure 4E

15 Continue pulling until the internal bumper sits flush against the anterior gastric wall Figure 4F

16 Cut the gastrostomy tube and place the external bolster onto the feeding tube Figure 5A

17 Push the external bolster so that it gently secures the tube in place, making note of the markings on the tube Figure 5B

18 Apply antibiotic ointment between the external bolster and skin surface Figure 5C

19 Thread the C-clamp onto the gastrostomy tube Figure 5D

20 Insert gastrostomy tube adapter to the end of the tube Figure 5E

by the markings on the tube. This may vary depending A skin disc is secured over the feeding tube to keep it in on the patient’s body habitus. Care should be made to place (61,62). ensure that the bolster is neither too tight nor too loose to The per-oral pull and per-oral push techniques, however, prevent buried bumper syndrome or leakage, respectively may not be possible or may be contraindicated in a variety (Figure 5B). Antibiotic ointment is applied between the of clinical scenarios. For example, patients with head and bumper and the skin (Figure 5C). A clamp and an external neck or esophageal cancer may have high-grade stenosis port are added to the PEG tube to complete the procedure preventing the passage of the endoscope or the internal (Figure 5D-5F). The external bolster should be evaluated the PEG tube bumper. Additionally, in patients with head and day after the procedure to ensure appropriate positioning. If neck cancer, the passage of the tube through a primary site the bolster is too tight, it may need adjustment or loosening. of malignancy may result in the implantation of cancer cells to the gastrostomy tube site resulting in abdominal wall metastasis (63). Per-oral push technique

In the Sacks-Vine technique (per-oral push), the feeding Introducer PEG technique tube is passed over the wire and pushed down through the stomach until the tapered end emerges through the skin. For these patients, the Introducer PEG technique is an The guide wire is then withdrawn and the endoscope is alternative to overcome the limitations of the traditional reinserted to ensure proper positioning of the feeding tube. per-oral pull or push techniques (63). In the introducer

A B

C D

Figure 2 Pre-procedural evaluation for PEG tube placement. (A) Patient’s abdomen marked with a surgical pen prior to the procedure; (B) endoscope retroflexed, evaluating the gastric cardia for lesions; (C) evaluating the duodenum for evidence of post-pyloric obstruction; (D) evaluating the esophagus for lesions.

PEG method, once the site of the gastrostomy is identified Another potential advantage of the introducer technique by trans-illumination and finger indentation, two to four is that it avoids passage of the feeding tube through the sutures are placed under endoscopic guidance resulting oropharynx, thus preventing translocation of bacteria to in a gastropexy of the anterior gastric wall to the ventral the peristomal site. Several studies have suggested that abdominal wall. An incision is made between the sutures there is a lower rate of peristomal skin infection associated and a trocar with a peel-away sheath is introduced through with the introducer technique as compared with the per- the abdominal wall into the stomach. Alternatively, a oral pull technique for PEG tube placement (64,65). One guidewire can be introduced using the Seldinger technique randomized control trial has even suggested that with the with progressive dilation of the gastrostomy. The peel- introducer method, prophylactic antibiotics may no longer away sheath is then introduced following dilation. A feeding be needed (66). tube is advanced through the sheath, which is then peeled off. An inflatable balloon at the tip of the feeding tube is Percutaneous ultrasound gastrostomy (PUG) technique filled with saline and serves as the internal bumper. A skin disc secures the tube externally. The gastropexy sutures PUG is an alternative to the standard PEG techniques. are then removed. This technique can be used in patients It utilizes magnetic coaptation and ultrasound guidance with high-grade stenosis in the oropharynx or along the instead of endoscopic guidance. The Point-of-care esophagus since it allows for use of an ultra-thin endoscope. Ultrasound Magnet-Aligned Gastrostomy (PUMA-G) Additionally, given that gastropexy is first achieved, this by CoapTech™ is the first system that has been approved technique has been safely used in patients with ascites. by the US Food and Drug Administration (FDA) for this

A B

C D

E F

G H

Figure 3 Insertion of the guidewire into the stomach. (A) Finger indentation at the site of trans-illumination; (B) indentation visualized from inside the stomach; (C) lidocaine with epinephrine administered at 90-degree angle to the surgical site; (D) small skin incision made with a scalpel at 90-degree angle; (E) insertion of the needle-catheter combination (trocar) through the incision at 90-degree angle; (F) visualization of the trocar from inside the stomach; (G) catheter positioned inside the stomach with the needle withdrawn; (H) snare system is passed through the endoscope and catches the wire loop.

A B

C D

E F

Figure 4 Placement of the PEG tube via the pull method. (A) Guidewire with wire loop pulled out of the mouth; (B) lubricating gel applied to the PEG tube prior to insertion; (C) PEG tube looped through the guidewire; (D) PEG tube attached to the guidewire via a knot; (E) firm pressure applied while pulling the PEG tube through the abdominal wall; (F) direct visualization of the PEG tube bumper from inside the stomach. PEG, percutaneous endoscopic gastrostomy. technique (67). magnetic force between the internal bar magnet and the In this technique, an existing orogastric or NGT in EHM bring the gastric wall and abdominal wall together the stomach is used for insufflation. Then a specialized to achieve a magnetic gastropexy. The GTB is then filled orogastric tube with a distal balloon, housing a bar magnet, with saline via a Luer lock at the proximal end of the gastric is passed from the mouth into the stomach. A wire stylet tube. A handheld ultrasound is used to localize the saline is placed inside the tube to assist in the placement of the filled GTB. Next, an introducer needle is inserted under gastric tube balloon (GTB) within the stomach (Figure 6). direct ultrasound guidance into the saline-filled GTB. Once the GTB is placed within the stomach, the wire stylet Subsequently, a guidewire with a coiled tip is inserted is removed and an external handheld magnet (EHM) is through the needle. Upon exiting the needle, the guidewire then placed over the GTB and used to move the GTB. The expands into its coiled configuration. The GTB is deflated

A B

C D

E F

Figure 5 Completion of the PEG tube procedure. (A) External bolster placed onto the PEG tube; (B) skin marking on the external bolster kept at 2–5 cm depending on the patient’s body habitus, making sure that the bolster is neither too tight nor too loose; (C) application of antibiotic ointment at the surgical site; (D) clamp positioned onto the PEG tube; (E) external port attached to the PEG tube; (F) successful placement of the PEG tube. PEG, percutaneous endoscopic gastrostomy. to capture the coiled end of the guidewire within the had their gastrostomy tubes placed successfully, and none balloon. The GTB catheter and guidewire is then pulled had complications in the 30 days following tube placement. out of the mouth and a gastrostomy tube is fed over the In this early experience, the average time for gastrostomy guidewire in similar fashion as the Sacks-Vine per-oral push tube placement with the PUMA-G technique compared technique. with standard PEG tube placement techniques was longer. The safety and efficacy of the PUMA-G technique has Additionally, fluoroscopy was required to localize the been demonstrated in case series of five patients. All patients GTB within the stomach and to guide EHM placement

Ultrasound Introducer needle Probe

Bar magnet

EHM

GTB Coiled end of the guidewire

Figure 6 Illustration of the percutaneous ultrasound gastrostomy technique. in 2 out of 5 patients, suggesting a learning curve for the immunosuppression, and underlying medical comorbidities. operator (68). A second study (published in abstract form) As such, current guidelines recommend use of prophylactic also showed efficacy of the PUG with magnetic gastropexy antibiotics prior to PEG placement to minimize the technique, demonstrating success in 15 of 20 patients. In risk of peristomal infection. In patients not allergic to these patients that were evaluated, fluoroscopy was used penicillin (PCN), a cephalosporin or PCN antibiotic to facilitate gastrostomy placement 95% of the time (69). should be administered 30 minutes before the procedure. However, both studies postulated that with continued Patients should also be screened for methicillin-resistant operator experience PUG is feasible without fluoroscopy. Staphylococcus aureus (MRSA). Patients who test positive PUMA-G offers the advantage over traditional PEG for MRSA should undergo decontamination and receive tube techniques in that it can be done at the bedside prophylactic vancomycin (70). with an ultrasound. The per-oral pull, per-oral push, and introducer techniques for PEG tube placement require Contraindications specialized medical personnel and costly equipment. These may not be available in under-resourced settings and can Contraindications to PEG tube placement include severe be more expensive. However, further studies are needed to coagulopathy, colonic interposition, history of subtotal or explore the safety and efficacy of the PUMA-G technique total gastrectomy, hemodynamic instability, sepsis, severe in comparison to standard PEG techniques. Another ascites, peritonitis, abdominal wall infection at the insertion limitation of the PUMA-G system is that the EHM has site, peritoneal carcinomatosis, gastric outlet obstruction, only been FDA approved for gastropexy in patients with and history of gastric varices (71). abdominal wall thickness ≤4.5 cm and maximal body mass index (BMI) between 30–35 kg/m2 (67,68). Obesity

Obesity, as defined by BMI >30 kg/m2, can make trans- Prophylactic use of antibiotics illumination more challenging and additional pressure Patients who are candidates for PEG placement are is required on the abdominal wall to obtain successful often also at high risk of infection given malnutrition, trans-illumination. However, obesity is not a strict

© Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2021;13(8):5277-5296 | http://dx.doi.org/10.21037/jtd-19-3728 5288 Wei et al. PEG tube placement in the ICU contraindication to PEG tube placement. PEG tube Initiation of tube feeding after PEG placement placement in overweight and obese patients can be done Enteral feeding is generally initiated 12–24 hours after without increased risk of complications compared to PEG tube placement. Despite its popularity, this practice patients with normal BMI (18–25 kg/m2) as long as there is not based on evidence from randomized controlled is good trans-illumination and indentation, and colonic trials. Kirby et al. in 1986 published one of the earliest interposition is not suspected (72,73). studies that documented the efficacy and safety of same day Mackenzie et al. evaluated placement of direct feeding (84). Early feeding following PEG tube percutaneous endoscopic jejunostomy (DPEJ) in obese and placement has been demonstrated to be safe by a number overweight patients (BMI >25 kg/m2) and found decreased of subsequent prospective studies (85-88). Early tube success with a trend towards increased complications as feeding allows for earlier achievement of goal nutritional compared to patients with normal BMI (74). Safe and rates, potentially reducing healthcare costs by shortening successful PEG tube placement has been documented inpatient hospitalization. in a case series of super-morbidly obese patients One meta-analysis by Bechtold et al., demonstrated (BMI >60 kg/m2) (75). that early (<4 hour) feeding is safe and well tolerated when compared to delayed or next day feeding following PEG Pregnancy tube placement (89). A more recent meta-analysis by Szary et al., also showed that early (<3 hours) feeding is safe when PEG tubes are generally not used in pregnancy. This is due compared to delayed feeding (90). to the concern for uterine or fetal damage, the alteration of the intra-abdominal anatomy by the enlarging uterus, and the risk of infection. Nevertheless, there have been several Complications case reports of successful PEG tube placement in pregnant Acute complications patients with severe refractory hyperemesis gravidarum or who were comatose following trauma (76-79). Patients who undergo PEG tube placement are at risk for procedural complications. While the risk is relatively low (0.1%), the procedure can be associated with significant Ascites morbidity and mortality. Possible complications from Ascites is a relative contraindication for PEG tube an endoscopy-guided procedure include aspiration, placement, as it poses technical challenges for the procedure hemorrhage, and perforation. Sedation carries the risk of itself and increases risk of complications following the aspiration, hypotension, and hypoxia (12). procedure. Ascitic fluid can make puncturing the anterior wall of the stomach more challenging. Ascites increases the Bleeding intraperitoneal distance and can predispose to PEG tube dislodgement. Furthermore, ascitic fluid may prevent the The post PEG-procedure bleeding risk is 2–2.5%. The maturation of a PEG tube tract thereby increasing risk of current American Society for Gastrointestinal Endoscopy gastric fluid leakage and peritonitis. (ASGE) guidelines state that aspirin and low dose However, Galaski et al. showed that in cases of nonsteroidal anti-inflammatory drugs (NSAIDs) can be malignant bowel obstruction, a palliative PEG tube for continued in patients at high-risk for thromboembolic decompression can be performed successfully. These disease. In patients with low thromboembolic risk, the patients first had their ascites drained via placement of decision to hold aspirin or NSAIDs is left to the discretion an intraperitoneal catheter, which was then followed by of the operator. In patients with low thromboembolic placement of a PEG tube. While these patients have a risk, thienopyridines (e.g., clopidogrel) should be held higher risk of complications, PEG tube placement is for 7–10 days prior to the procedure. In patients with a feasible procedure (80,81). Furthermore, the use of high thromboembolic risk, PEG tube placement should gastropexy can be used to prevent ascitic leakage around the be delayed until the thienopyridine can be safely held. PEG tube (82,83). However, some studies have suggested that clopidogrel can

© Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2021;13(8):5277-5296 | http://dx.doi.org/10.21037/jtd-19-3728 Journal of Thoracic Disease, Vol 13, No 8 August 2021 5289 be safely continued for PEG tube placement (91,92). as high as 23–35%. Risk factors for clogging include use of Interestingly, Richter et al. found that while the use of thick enteral feeding formulas, use of bulking agents, and aspirin or clopidogrel was not associated with increased risk use of smaller bore feeding tube (8–9 Fr). For this reason, of bleeding, serotonin reuptake inhibitors have been linked we use a 20 Fr feeding tube at our institution for most cases. to increased risk of bleeding (93). One study showed that with increased acidity, particularly Warfarin should be held for 4–7 days prior to the with pH <5.0, proteins become less soluble, increasing the procedure. Warfarin should be bridged if patients are at risk of gastrostomy tube clogging (101). Prophylactic use of higher risk for thromboembolism such as those with valvular pancreatic enzymes with sodium bicarbonate mixture has atrial fibrillation, mechanical heart valves, left ventricular shown to be effective in maintaining tube patency (102,103). assist devices, or recent diagnosis of thromboembolism. Bleeding can usually be controlled with pressure over the Buried bumper syndrome (BBS) abdominal wound. In the case of delayed external bleeding at the incision site, we use topical tranexamic acid (5 mL) BBS is a severe complication of PEG tube placement which and oxidized regenerated cellulose (Surgicel™). If there is occurs when the internal bumper migrates along the stomal any concern for internal bleeding, endoscopic or surgical tract and is displaced outside of the gastric wall. This often exploration of bleeding source may be required, and the use occurs as a result of excessive compression between the of endoscopic clips may be needed for hemostasis (38). internal bumper and external bolster. The incidence of BBS has been noted to be around 1% (0.3–2.4%). BBS can lead to gastrointestinal bleeding, perforation, peritonitis, or Peristomal wound infection intra-abdominal abscess or phlegmon. Peristomal wound infection is the most common Patient specific risk factors for developing BBS complication of PEG tube placement with an incidence include old age, immunosuppression, malnutrition, and ranging from 4–30% (87). Three quarters of these infections treatment with steroids or chemotherapy. Internal bumper are minor and resolve with antibiotic treatment (94). characteristics, PEG tube characteristics, and the quality Several randomized control studies have shown that of long term gastrostomy site care can affect the risk of antibiotic prophylaxis reduces the risk of peristomal wound developing BBS. Internal bumpers made of rigid or semi- infection compared to placebo (95-97). rigid material or those with small contact area, sharp This has been confirmed by a meta-analysis, which edges, or conical shape are at risk for developing BBS. showed that the use of prophylactic antibiotics prior to Tubing with jejunal extension can cause the tubing to be PEG placement was associated with a 64% relative risk positioned tangentially rather than perpendicularly, which reduction and a 15% absolute risk reduction in peristomal also increases risk for developing BBS. It is recommended wound infections. The number needed to treat to prevent that as a preventative measure, the external bolster should one wound infection was eight (98). One study showed be positioned about 10mm away from the skin. Permanent that nasopharyngeal decolonization of MRSA significantly dressing between the external bolster and the skin or reduced peristomal infection rates among patient colonized excessive tightening of the external bolster can increase the by MRSA (99). risk for BBS. The timing of relaxing the external bolster Recent double blind, randomized control studies positioning to 10mm is controversial. Some operators evaluating the modified introducer technique have prefer a tighter positioning of the external bolster in the suggested that prophylactic antibiotics may not be needed first four days after PEG tube placement to prevent leakage in the modified introducer technique. This technique, as at the stoma (104). described earlier, does not require passage of the feeding tube through the mouth thus minimizing translocation of Tumor tract seeding the oral flora to the stoma site, which occurs with the per- oral push and per-oral pull techniques (66,100). There is also a small but definite risk of tumor metastasis following PEG tube placement in patients with untreated head and neck cancers. One retrospective review of 304 Clogged feeding tube patients with active head and neck cancer who underwent The incidence of clogged feeding tube has been reported PEG placement noted a risk of 0.92% of developing

© Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2021;13(8):5277-5296 | http://dx.doi.org/10.21037/jtd-19-3728 5290 Wei et al. PEG tube placement in the ICU abdominal wall metastasis (105). It has been suggested that puncture of overlying bowel or erosion over time the risk of tumor metastasis from head and neck cancer may into adjacent intestine (112,114). Risk factors include be minimized with the use of the introducer technique for insufficient gastric insufflation, inadequate trans- PEG placement (106). illumination, or presence of adhesions which may result in trapped intestines. Patients may present acutely with peritonitis, fasciitis, or intestinal obstruction. However, Inadvertent tube removal more commonly the presentation is insidious, with leakage The rate of early PEG tube dislodgement has been of fecal contents through the peristomal site or with reported as 0.6–4.0%. When followed longitudinally for watery diarrhea resembling tube feed formula. If a fistula the lifetime of a new PEG, PEG tube dislodgement rates is suspected, the patient should have a contrast study to were observed to be 12.8%. Dislodgement within 7 days confirm the anatomy (115). The fistulous tract can be of PEG tube placement, before the gastro-cutaneous tract managed conservatively by removal of the PEG tube and has a chance to mature, results in an open gastrostomy. allowing for spontaneous fistula closure. In patients with This allows for leakage of gastric contents and tube feeds large fistulas or delayed wound healing, the fistula can be into the intraperitoneal space, resulting in significant closed surgically or endoscopically (116,117). morbidity (107). In patients who are disoriented or combative and at Interventional pulmonologists high risk of early tube dislodgement, various techniques have been described to minimize the risk of dislodgement, Interventional pulmonologists have expertise with including endoscopic sutures, T-fasteners, and novel endoscopic and procedural interventions. They are bumper designs (108-111). comfortable placing tracheostomies, which often are required in patients who simultaneously require PEG tube placement (118,119). Therefore, the next logical evolution Peristomal leakage/irritation would be for interventional pulmonologists to perform both The reported incidence of peristomal leakage is around procedures at the same time when indicated. This would 1–2%, but the actual incidence is likely much higher. Risk minimize the risks associated with sedation and paralytics as factors for peristomal leakage include delayed wound the two procedures can be merged into a single coordinated healing, infection, gastric hypersecretion, excessive cleaning procedure performed by the same physician. with hydrogen peroxide, BBS, and torsion or instability One small retrospective study demonstrated that of the PEG tube. Patients should be optimized from a interventional pulmonologists were able to place PEG nutrition and glycemic control standpoint preceding the tubes at bedside with 97.2% success rate (70 of 72 patients). PEG procedure. Forty-one of the 70 PEG tubes placed (58%) were Skin protectants and barrier creams such as zinc oxide performed immediately after percutaneous tracheostomy. should be applied. Excessive torsion applied by the external There were no complications associated with PEG tube bumper should be relieved. Proton pump inhibitors should placement. Mild cellulitis around the PEG tube site was be initiated to minimize gastric acid secretion. noted in 1 patient (1.4%). This study found a 30-day It is not recommended to exchange the PEG tube to a mortality rate of 11.94% as compared with 25% in larger bore tube as this would result in enlarging the gastro- gastroenterology literature (120). cutaneous fistula and potentially exacerbate the problem. Another prospective study demonstrated similar efficacy One strategy is to remove the PEG tube and allow the fistula and safety of PEG tube placement with bronchoscopic to close before placing a new PEG tube. However, this can guidance in the ICU by interventional pulmonologists with only be done once the gastro-cutaneous fistula tract has fully a 97.6% success rate and 2.4% complication rate. Only matured. As a last resort, the PEG tube can be removed and minor complications including soft tissue infection and another PEG tube can be placed at a different site (112,113). G-tube malfunction were noted. No major complications were noted. 30-day mortality in this study was 11.9% (121). However, we prefer endoscopic rather than Gastro-colocutaneous fistulas bronchoscopic assisted PEG placement since complete Gastro-colocutaneous fistula can arise from inadvertent EGD is not possible with a bronchoscope. EGD is necessary

© Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2021;13(8):5277-5296 | http://dx.doi.org/10.21037/jtd-19-3728 Journal of Thoracic Disease, Vol 13, No 8 August 2021 5291 to rule out post-pyloric obstruction. Additionally, adequate commercial replication and distribution of the article with insufflation and trans-illumination with examination of the the strict proviso that no changes or edits are made and the gastric cardia by retroflexion is not always possible with a original work is properly cited (including links to both the bronchoscope. formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Wei M, Ho E, Hegde P. An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit. J Thorac Dis 2021;13(8):5277-5296. doi: 10.21037/jtd-19-3728